Provider Demographics
NPI:1902977242
Name:SCOTT E SOUTHWORTH MD PC
Entity Type:Organization
Organization Name:SCOTT E SOUTHWORTH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:SOUTHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-294-9333
Mailing Address - Street 1:140 N UNION AVE STE F-300
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2953
Mailing Address - Country:US
Mailing Address - Phone:801-294-9333
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4968
Practice Address - Country:US
Practice Address - Phone:801-294-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT200632514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528924674003Medicaid
UTDF2387Medicare PIN
UT000059620Medicare PIN